My personal journey at THI – Dr. Nikhil Dhanpal

(This article was initial shared with the alumni of St.Johns Medical College Bangalore)

During a confusing time in my life when I had almost finished my internship and had to make decisions about what my next step would be I had the good kismet of meeting Dr.Ravi Narayan-an old Student of St.John’s who runs an NGO-SOCHARA in Bangalore whose son Lalit had worked in THI. He made me think about the larger picture told me about the abysmal state of healthcare in many parts of India with some astounding statistics! He also encouraged me to work for in an area of need to really get to know my country and referred me to ‘Tribal Health Initiative’(henceforth referred to as THI)- A hospital that catered to the healthcare needs of a remote Tribal Community in Tamil Nadu.

My interest piqued, I did a little research and decided to visit THI along with a friend the following week and met with Dr.Regi whose post would be difficult to describe (if you could find a term for anaesthetist ,surgeon, sonologist, managing trustee, organic farmer , voluntary wildlife warden, ornithologist combined- that word would just about describe him). Little did I know that this was an informal interview. Regi is aged about 50, dressed in kadhi who greeted me with a disarming smile and a reassuring handshake. What was supposed to be a brief meeting turned out to be a long conversation about healthcare, St. Johns, the history of THI , his experiences, metaphysics, his Buddhist philosophies, the fall of the Ottoman empire and other such matters of great consequence . When we finally realized the time, it was 3:30 in the afternoon and Manu was probably cursing the day he agreed to come with me. After a tour around the place and a look at my future cottage, I was hooked.

A LITTLE HISTORY

THI was started by Dr.Regi George and his wife Dr.Lalitha in 1992 in the Sittilingi valley. The Sittilingi Valley is nestled between the Kalryan and the Sittheri hill ranges, surrounded completely by deciduous forest and comes under the Dharmapuri district of Tamil Nadu though the closest urban centre is Salem. At the time of its inception there was no electricity, pucca road or public transport to the hospital much of which has changed now.

This remarkable Doctor couple met and fancied each other while in Med School in Kerala and decided to take the plunge. Having been inspired by the life and works of Albert Schwietzer they always had a yearning to make a difference in an area of need. They worked a few years at the Kasturba hospital for the poor at the Gandhigram trust –Dindugal and then Regi went on to specialize in Anaesthesia and Lalitha in OB/GYN. In order to find out where their services would be needed the most they went on a road trip to many preselected areas all over India travelling for over a year and decided to dedicate their services and build a hospital in the Sittilingi valley after extensive research .

At that point of time the Valley composed predominantly of tribal people and had one of the highest MMR and IMR in India with deaths due to preventable illness very common place. What started at a single thatched roof hut in 1992 is now a 30 bedded hospital with 2 operating rooms, a well equipped lab ,a nursery, endoscopy, pharmacy and other trappings of a self sufficient secondary hospital. There are also organic farming initiatives and tribal embroidery units that have been started to help augment incomes in lean periods of the year and also revive the dying designs of Lambadi embroidery.

THE REST OF THE TEAM

I also had the privilege of working with Ravi who after his MBBS volunteered at Sittilingi and then went on to do his Masters in Public Health from the London School of Tropical Medicine and Hygiene. Soon after he worked a few years at the Christian Hospital Bissamcuttack, Orissa in the community health program and in the Department of Surgery when he realized his forte was Surgery and then went on to specialize in surgery. It was in Bissamcuttack that he met his lady love Prema who was in charge of the nursing school who then went on to finish her Msc Nursing from CMC Vellore and the rest is history with them joining THI in 2012.

The nurses are all local tribal women selected from the community for their diligence, intelligence and empathy and have been trained over the years by Lalitha. It was impossible to get Nurses to work here so they managed to strike two birds with one stone, also generating local employment and increasing general awareness. They are currently the backbone of the hospital.

With Prema having joined us there is now a nursing course in place and we train 8 students per year with plans for a Tribal College of Nursing on the table.

PERSONAL EXPERIENCES

From collecting reports and writing discharge summaries I was suddenly a few days later in an Out patient with two or three other doctors and close to 250 patients all of whom have to be seen before 5 pm (that’s the last bus out). Being called in-between for other emergencies and surgery if necessary has taught me how to multitask. During the first few weeks I often wondered if I could ever cope with this breakneck pace and then I found myself learning how to prioritize and make best use of available time.

Language always seems to be a big barrier and my English and broken Kannada was of little help in Tamil heartland. With wonderful guides all around and plenty of teachers I picked up medical tamil quite soon and though my atrocious conversational tamil still brings tears to a few eyes (mirth and grief), I think I’ve managed to glean a decent amount of Tamil. I was also very touched as during my whole two years not a single person be it a patient or their family, nurses or general public ever dismissed or ignored me for not knowing tamil nor was it an impediment to build relationships. The respect that tribals have for each other and which they accord to you when they identify with you is truly unique and flattering.

From studying and training in an atmosphere where the hierarchy is so rigid it was quite a task to cope to an environment where you are treated as an equal. The rest of the hospital, patients and me always referred to Regi as Gi and Lalitha as Tha, no sirs and ma’ms . It was hard the first two weeks as I would say Sir or Ma’m by default and would be gently reminded that its Gi or Tha . They also firmly believed that the work you do speaks for itself and there was no dress code, after observing my initial attire of pressed formals Regi told me that I would probably be more comfortable in slacks and t- shirts. I also learnt that no work is beneath you – we started the day with 5 minutes of silent meditation followed by communal cleaning of the campus , some days cleaning of the toilets led by Lalitha and some days firing the incinerator by turn- everyone was expected to do these jobs. In patient care –starting an IV, helping patients to the toilet or with a bed pan administering drugs if needed .You feel odd for not doing it when someone older and more senior than you does it with no misgivings and then you learn to love it.

Some days you would be woken up to problems like ‘Anna(term of endearment) the borewell motor isn’t working” or “Anna the Autoclave isnt running and today is Theater “. The hospital being partly solar, AC current and diesel generator hardly helped matters (The entire circuitry was designed by a group of students from IIT Chennai as a summer project so it was complicated as hell! ) as we had to shift between each depending on the voltage and where the maximum use was at that time. Basic knowledge of the circuits and strong eardrums to withstand the ancient generators’ protests were necessary.

The campus being Gandhian the meals were frugal and intoxicants were really not encouraged .The meals though basic were made with love and we had to eat under the watchful eyes of Big Mama(Davaminamma) who always knew exactly how many dosais you’ve eaten and would try to trick you into eating more by telling you she would put one more on your plate while holding five! The trick to enjoying every meal was to stay hungry, then everything tastes amazing .

Its easy to sit in an OPD and chide someone for not coming earlier or for delaying your lunch break but its only when you really see how far away people live that you truly empathize. By visiting villages on weekly visits for the ANCs and the under fives , sometimes on foot for miles beyond where the Jeep wouldn’t go I had a real insight into how far people really live and how poor the connectivity really was. Its also because of these observations that you appreciate the smaller things in life like electricity running water and a seat on an extremely crowded bus or a hot home cooked meal that are things considered a luxury by a majority.

In my first week Regi had told me that there was one skill that I should master before I leave, I thought he would say something like Caesareans or hernias or something, but he said that all junior doctors should learn to catch snakes! Killing of snakes was prohibited on campus unless poisonous and imminent danger was likely. So any snake spotted had to be caught without harming it and transported in a gunny sack to the forest where it was released. I managed to catch a small non poisonous wolf snake once though I’ve never had the chance to do it again.

We had an active field program where we trained health workers who lived in the villages to be a first contact for any person requiring medical assistance and also to function as advocates of family planning immunization nutrition etc. they were pretty much hybrids between an ANM and an Anganwadi worker. These workers required monthly classes and updated us on deaths births in the villages etc to help keep an accurate census. Bi weekly classes by each doctor for the nursing students also helped improve my teaching skills.
Having enjoyed a great relationship with the nurses along with the wealth of knowledge I gained from them makes me respect workers at every level. My complete practical obstetric knowledge of differentiating all the aspects of the bishop’s score to dosing the oxytocin to applying an outlet forceps are skills that were imparted to me by the nurses in the labour room .

All the above are things which I felt made THI very different from other hospitals and I haven’t emphasized on the usual surgical work caesareans , hernias ,hydrocoeles ,appendectomies , perfs etc with Ravi and Regi holding my hand intra op while teaching is invaluable to me as I aspire to be a surgeon. Medical emergencies-poisonings, MIs, Status many things, CVAs and all nighters for critical patients or while transporting patients have given me quite a lot of confidence. Referral to a larger hospital is not always an option and sometimes the guilt of not being able to provide optimal care was quite overwhelming.

I could keep going on and on as lessons over two years cannot be conveyed over a few pages, so I will stop. I would like to thank you immensely for having read this long winded soliloquy of mine and would be grateful for any comments that you may have.

Nikhil,
Very touching indeed ! I have read it twice, brings tears to my eyes !! Hopefully you would be there in Jan 2016- I plan to visit THI ( for a few hours at least ) and meet all of you. Please ask ” Gi” about me – he may be able to tell you more .
Best wishes
Manohar Nallathambi